Genital Warts (Condyloma Acuminata)
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Direct answer
Genital warts are soft, fleshy, cauliflower-like growths caused mainly by human papillomavirus types 6 and 11, which are low-risk types that rarely turn malignant. Diagnosis is usually clinical, with biopsy reserved for atypical lesions. In pregnancy, podophyllin and podofilox are avoided, so warts are treated with trichloroacetic acid, cryotherapy or surgical removal, and caesarean is not indicated for warts alone.
What you must remember
- Causative types: HPV 6 and 11 cause most genital warts; HPV 16 and 18 are high-risk types linked to cervical cancer, not to the typical wart.
- Appearance: Soft, pink or white papules or cauliflower-like masses on the vulva, perineum, perianal skin or vagina, often multiple.
- Biopsy triggers: Pigmented, ulcerated, indurated, bleeding, enlarging or treatment-resistant lesions need biopsy to exclude intraepithelial neoplasia or carcinoma.
- Avoid in pregnancy: Podophyllin and podofilox, which are toxic when absorbed; imiquimod has limited safety data and is avoided.
- Pregnancy options: Trichloroacetic acid or bichloroacetic acid, cryotherapy and surgical excision are the usual choices.
- Delivery: Large lesions obstructing the birth canal may need caesarean; the risk of transmission to the newborn is too low to justify caesarean for warts alone.
- Prevention: HPV vaccination is not given in pregnancy and is given before sexual exposure; postpartum vaccination is an option for unvaccinated women.
A clinic pathway from examination to delivery
Management depends on the size, number and site of the warts, and on whether the woman is pregnant. The pathway below is followed before a treatment is chosen.
- Examine the whole anogenital area: Look at the vulva, perineum, anus and vagina, and examine the cervix with a speculum, because vaginal and cervical lesions are often missed.
- Check for red flags: Biopsy any lesion that is pigmented, ulcerated, indurated, bleeding or resistant to treatment.
- Check pregnancy status first: Podophyllin and podofilox are not used in pregnancy, so this check decides the treatment options.
- Choose a clinic-applied treatment: Trichloroacetic acid or bichloroacetic acid is applied to small lesions, with cryotherapy as an alternative.
- Excise large or resistant lesions: Surgical excision or laser ablation is used for bulky or resistant warts, often under local anaesthesia.
- Plan delivery and follow-up: Reassess lesions in the third trimester; obstructing lesions need a delivery plan, and recurrence after delivery is common.
Where the examiner tries to catch you
Viva questions on warts test the HPV types, the pregnancy drug list and the delivery decision.
- Trap: Linking HPV 6 and 11 warts to cervical cancer Correct: Types 6 and 11 are low-risk and cause warts, whereas types 16 and 18 cause most cervical cancers.
- Trap: Advising caesarean because the woman has genital warts Correct: Caesarean is reserved for lesions that obstruct the birth canal, not for warts alone.
- Trap: Prescribing podophyllin for a pregnant woman with warts Correct: Podophyllin is toxic when absorbed and is avoided in pregnancy; trichloroacetic acid or cryotherapy is used instead.
Frequently asked questions
Which HPV types cause typical genital warts?
HPV types 6 and 11 cause most typical genital warts and are classed as low-risk types. HPV 16 and 18 are high-risk types linked to cervical and other anogenital cancers, not to the common wart.
Is podophyllin safe for genital warts in pregnancy?
Podophyllin is not safe for genital warts in pregnancy because it is absorbed systemically and can cause serious toxicity. Trichloroacetic acid, bichloroacetic acid or cryotherapy is used instead for pregnant women.
Do genital warts alone require caesarean section?
Genital warts alone do not require caesarean section. Caesarean is considered only when large lesions obstruct the birth canal, because the risk of transmitting HPV 6 and 11 to the newborn does not justify it on its own.
When should HPV vaccination be given in relation to pregnancy?
HPV vaccination is not given during pregnancy, and it is best given before sexual exposure. Postpartum vaccination is an option for women who were not vaccinated before pregnancy, as per current guidance.